Covered Entity Details

CAH161322-02 Dallas County Hospital (Active) - information as of 6/12/2025 9:48:31 PM

Main Details

Name

Dallas County Hospital

Subdivision Name

DCH FAMILY MEDICINE - FAMILY MEDICINE

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH161322-02

Medicare Provider Number

161322

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/27/2020

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Dallas County Hospital
Angela Mortoza, Chief Executive Officer
(515) 465-7628

Primary Contact

Dallas County Hospital
Tricia Kay Steiner, CPC, Compliance and Risk Coordinator, Privacy Officer
(515) 465-7555

Addresses

Street Address

319 E. Main St.
PANORA, IA 50216

Billing Address

Dallas County Hospital
610 10th St.
PERRY, IA 50220

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH161322-01	Child	CAH	Dallas County Hospital	DCH FAMILY MEDICINE PERRY - Family Medicine	616 10TH ST	PERRY	IA	Active
CAH161322-02	Child	CAH	Dallas County Hospital	DCH FAMILY MEDICINE - FAMILY MEDICINE	319 E. Main St.	PANORA	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 10:36:27 AM	8/22/2024 2:03:06 PM	8/22/2024 2:03 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 10:14:53 AM	8/17/2023 10:36:27 AM	8/17/2023 10:36 AM
Addresses	Main Address	Update	Recertification	319 E. Main St. Panora PANORA, IA 50216	319 E. Main St. PANORA, IA 50216	8/31/2022 10:14 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 11:17:49 AM	8/31/2022 10:14:53 AM	8/31/2022 10:14 AM
Details	Last Recertification Date	Update	Recertification		8/24/2021 11:17:49 AM	8/24/2021 11:17 AM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Mortoza, Angela Chief Executive Officer Dallas County Hospital 5154657628	10/27/2020 10:01 AM
Details	340B ID	Update	New Registration		CAH161322-02	10/27/2020 10:01 AM
Details	Entity Name	Update	New Registration	DALLAS COUNTY HOSPITAL	Dallas County Hospital	10/27/2020 10:01 AM
Details	Entity Subname	Update	New Registration	DCH FAMILY MEDICINE	DCH FAMILY MEDICINE - FAMILY MEDICINE	10/27/2020 10:01 AM
Dates	Participating Approval Date	Update	New Registration		10/27/2020 10:01:23 AM	10/27/2020 10:01 AM
Details	State	Update	New Registration	Pending	Approved	10/27/2020 10:01 AM
Dates	Signed By Date	Update	New Registration		10/26/2020 1:48:02 PM	10/27/2020 10:01 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/27/2020 10:01 AM
Addresses	Main Address	Insert	New Registration		319 E. Main St. Panora PANORA, IA 50216	10/9/2020 2:46 PM
Addresses	Billing Address	Insert	New Registration		Dallas County Hospital 610 10th St. PERRY, IA 50220	10/9/2020 2:46 PM
Contacts	Authorizing Official	Insert	New Registration		Mortoza, Angela Chief Executive Officer Dallas County Hospital 5154657628	10/9/2020 2:46 PM
Contacts	Primary Contact	Insert	New Registration		Steiner, Tricia Kay CPC, Compliance and Risk Coordinator, Privacy Officer Dallas County Hospital 5154657555	10/9/2020 2:46 PM
Details	Assistance Received From Date	Insert	New Registration			10/9/2020 2:46 PM
Details	Assistance Received To Date	Insert	New Registration			10/9/2020 2:46 PM
Details	Last Recertification Date	Insert	New Registration			10/9/2020 2:46 PM
Details	Grant Number	Insert	New Registration			10/9/2020 2:46 PM
Details	340B ID	Insert	New Registration			10/9/2020 2:46 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2020 2:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2020 2:46 PM
Details	Medicare Provider Number	Insert	New Registration		161322	10/9/2020 2:46 PM
Details	Entity Name	Insert	New Registration		DALLAS COUNTY HOSPITAL	10/9/2020 2:46 PM
Details	NOFO Number	Insert	New Registration			10/9/2020 2:46 PM
Details	Program Code	Insert	New Registration		CAH	10/9/2020 2:46 PM
Details	Entity Subname	Insert	New Registration		DCH FAMILY MEDICINE	10/9/2020 2:46 PM
Dates	Participating Approval Date	Insert	New Registration			10/9/2020 2:46 PM
Details	State	Insert	New Registration		Pending	10/9/2020 2:46 PM
Dates	Registration Date	Insert	New Registration		10/9/2020 2:46:35 PM	10/9/2020 2:46 PM
Dates	Signed By Date	Insert	New Registration			10/9/2020 2:46 PM
Dates	Start Date	Insert	New Registration			10/9/2020 2:46 PM
Terminations	Termination Comments	Insert	New Registration			10/9/2020 2:46 PM
Terminations	Termination Date	Insert	New Registration			10/9/2020 2:46 PM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2020 2:46 PM
Terminations	Termination Reason	Insert	New Registration			10/9/2020 2:46 PM